The House recently passed a budget reconciliation bill that includes national Medicaid work requirements for adults in the Affordable Care Act (ACA) expansion group, which the Congressional Budget Office (CBO) estimates would reduce federal Medicaid spending by $344 billion over ten years and increase the number of people without health insurance by 4.8 million. On June 16, the Senate Finance committee released proposed reconciliation language with some substantive changes to the Medicaid work requirement provisions, but this language may change as the Senate debates the bill. Under the House-passed bill, adults enrolled through ACA Medicaid expansion must complete 80 hours of work (or other qualifying activities) per month or meet specific exemption criteria (such as having a substance use disorder (SUD) or “disabling” mental disorder). States must verify compliance (at least) at application, renewal, and every six months thereafter, starting no later than December 31, 2026 or individuals could be denied or disenrolled from coverage. For additional details about this process, see KFF’s explainer.

Medicaid plays a large part in coverage and treatment of behavioral health conditions, covering nearly one-third of all adults with mental health disorders and one-fifth of all adults with substance use disorders; among Medicaid expansion enrollees specifically, 24% have a diagnosed behavioral health condition. Continuous Medicaid coverage supports ongoing treatment for mental health and substance use disorders, and disruptions may negatively affect individuals’ mental and physical health. Additionally, many adults with mild or moderate conditions already work or engage in qualifying activities but rely on Medicaid-covered medications and treatments to maintain steady employment. This brief describes key challenges that Medicaid work requirements may pose for adults with mental health or substance use disorders.

Medicaid expansion is the primary coverage pathway for people with mental health or substance use disorders. Among Medicaid-covered adults diagnosed with a substance use disorder, 59% qualify through ACA expansion, similar to those with opioid use disorders (61%), any mental health disorder (51%), and serious mental illness (45%, defined here as schizophrenia, other psychotic disorders, and bipolar disorders). These shares are higher when limited to ACA Medicaid expansion states (Figure 1). Others qualify for Medicaid by receiving Supplemental Security Income (SSI) for a disability, as a low-income parent, or pregnant/postpartum individual. Although certain serious mental illness diagnoses may qualify for SSI, the disability determination process is lengthy and complex, and overall two-thirds of Medicaid enrollees with disabilities qualify through non-disability pathways, such as Medicaid expansion. Substance use disorders alone do not qualify individuals for SSI.

The House-passed bill (and language proposed by the Senate Finance Committee) specifies exemptions for individuals with substance use disorders or “disabling” mental disorders from Medicaid work requirements under the “medically frail” designation. Participation in a SUD treatment program is also listed as an exemption in the bill. However, the bill does not explicitly define which diagnoses constitute “disabling” mental disorders. Mental health disorders that substantially impair daily functioning—such as schizophrenia, other disorders involving psychosis, or bipolar disorder—might be among those considered “disabling” mental disorders under the medically frail designation. However, the exact diagnoses qualifying for this exemption have not yet been clarified and will depend on forthcoming federal guidance and state decisions.

Federal and state decisions about implementing work requirements may be particularly impactful for adults with mental health or substance use disorders. However, the extent of the impact may depend heavily on how these requirements are defined and operationalized, and many details currently remain unclear. Upcoming federal guidance may provide some clarification, but processes could still vary by state. For example, the House bill does not specify how states would be expected to identify individuals who are exempt or whether/when individuals may be required to self-report or provide documentation to confirm they meet exemption criteria. Potential challenges include:

• The House bill does not specify states will be required to use available data to automatically verify exemptions, and even states using data may miss some individuals due to data limitations. While states could cross-reference Medicaid enrollment records with other data sources, such as Medicaid claims, to identify exemption-qualifying conditions like substance use disorders or certain mental disorders, there is often a delay of weeks or months between a service being delivered and claims being fully processed. The length of this delay may also differ by state and Medicaid managed care organization, the primary way most enrollees receive care. Claims further delayed due to disputes, denials, or bundling with other services can further obscure specific diagnoses. These data limitations could leave some exempt individuals unidentified, requiring them to initiate and navigate the state’s exemption process. States with outdated or less integrated data systems may face additional challenges, potentially increasing reliance on manual reporting—particularly difficult for individuals with mental health or substance use disorders. For example, when Arkansas implemented Medicaid work requirements, data-matching identified about two thirds of enrollees, exempting them from reporting work hours or exemption status. Among those who had to actively report, about 70% did not obtain an exemption or report compliance with the work requirements, ultimately resulting in over 18,000 people losing coverage. Arkansas is among a subset of states that already makes “medically frail” determinations because they opt to provide an “alternative benefit package” to ACA expansion adults, enrolling them in Marketplace health plans (while individuals designated “medically frail” may receive the “traditional” Medicaid benefit package). As a result, the state may be better positioned to conduct data matching for exemptions relative to other states; but still Arkansas highlighted (in its new waiver request) that limitations with “data matching” led to some individuals with medical conditions or disabilities that prevented them from working to “fall through the cracks” when the state implemented its work policies in 2018.

Common behavioral health symptoms would make it more challenging for individuals with these conditions to self-report work or exemption status. Behavioral health symptoms can include challenges with concentration, planning, energy levels, anxiety, feelings of overwhelm, and difficulties managing stress, all of which may make it harder for enrollees to understand requirements, navigate complex submission processes, and troubleshoot issues that arise. Individuals experiencing severe or acute behavioral health symptoms may find it particularly difficult to provide documentation, especially for those whose disorders are compounded by unstable employment, housing instability, or homelessness—which is more common among those with serious mental health disorders or severe substance use disorders. Therefore, mental health and substance use disorders themselves could increase the risk of Medicaid coverage loss under proposed requirements. Provider burden may increase if provider documentation is required to obtain an exemption. Under New Hampshire’s work requirement waiver, adults who self-attested to being medically frail were still required to obtain certification from a medical professional of their medical frailty exemption, which was reportedly difficult for enrollees to navigate and complicated for providers.

• Mild and moderate mental health disorders may not qualify adults for exemptions from work requirements; however, symptoms could lead to employment gaps, making compliance with new requirements more difficult. People with mild or moderate disorders can experience episodic symptoms, such as depressive episodes or severe anxiety, which can disrupt consistent employment. The House bill allows states to provide short-term hardship exceptions, such as during inpatient psychiatric stays; however, these exceptions are not federally required and must be requested by the enrollee. Additionally, variation in work requirement implementation could further affect compliance. For instance, states that require verification of work history over three consecutive preceding months may present greater compliance challenges compared to states with less stringent criteria.

• Individuals with new or undiagnosed behavioral health disorders may struggle to qualify or maintain Medicaid coverage without sufficient work history or formal diagnoses. Adults experiencing sudden symptoms, such as a first episode of psychosis, may face significant difficulties navigating exemption processes quickly, particularly at the onset of a disorder, which can be confusing and difficult in itself. Additionally, many adults have undiagnosed behavioral health disorders, an issue especially common among people with substance use disorders. If enrollees are required to submit an official diagnosis to receive an exemption, individuals without an official diagnosis remain subject to work and reporting requirements, potentially leading to coverage loss if symptoms disrupt employment. Even in states that use Medicaid claims data to identify exemptions, there is typically processing time between service dates and when the visit appears in claims data, which can delay states’ identification of individuals with new diagnoses. In addition, applicants with recent employment gaps due to mental health or substance use symptoms may face additional barriers documenting compliance or exemption status at enrollment. For example, Georgia—the only state currently requiring work compliance at Medicaid application—experienced significantly lower enrollment than anticipated due to these requirements, though it did not allow any exemptions.

Being in poor health is associated with an increased risk of job loss, while access to affordable health supports obtaining and maintaining employment. Regular access to care, including mental health and substance use disorder treatment, can help stabilize behavioral health symptoms. However, disruptions or losses in coverage can interrupt treatment, exacerbating these conditions. For instance, stopping medication for opioid use disorder significantly increases mortality risk, with individuals facing a six-fold greater risk of death in the four weeks immediately following treatment discontinuation.

According to the Associated Press, the Trump administration recently shared the personal and health data of millions of noncitizen Medicaid enrollees living in California, Illinois, Washington, and D.C. with immigration enforcement officials, despite concerns reportedly raised by some officials from the Centers for Medicare and Medicaid Services (CMS) about violations of data privacy protections. This policy watch discusses the data privacy protections in Medicaid and the implications of breaches or violations of those protections.

State Medicaid agencies collect and maintain personal and health information for applicants and beneficiaries to determine eligibility for coverage and provide care. This information includes personal identifying data, such as names, birth dates, and contact information; social security numbers; citizenship and immigration status; income; and health information. State Medicaid agencies cannot require applicants to provide information about the citizenship or immigration status of any family or household members not applying for coverage. Medicaid is jointly administered by the federal government and states, and states are required to share certain information with the federal government to administer the program.

Federal and state laws and regulations provide protections designed to safeguard applicant and enrollee data that limit the use and sharing of personal information for administering the program. For example, the Social Security Act and accompanying regulations require that the “the use or disclosure of information concerning applicants and beneficiaries” must be restricted to “purposes directly connected” with administering state health coverage programs and that states safeguard the information so that it is “protected against unauthorized disclosure for other purposes.” At a minimum, safeguarded information must include names and addresses, medical services provided, social and economic circumstances, agency evaluation of personal information, medical data, information for verifying eligibility and medical assistance payments, social security numbers, and any information received in connection with identification of legally liable third party resources. Consistent with these laws and regulations, prior guidance issued in 2013 clarified that Immigration and Customs Enforcement does not use these data to pursue civil immigration enforcement. Medicaid data are also subject to Health Insurance Portability and Accountability Act (HIPAA) standards that protect sensitive health information from disclosure without a patient’s consent. Some states also have their own data privacy laws that apply to Medicaid data.

Federal regulations also require states to publicize the confidential nature of information applicants and beneficiaries submit to them. Reflecting this requirement, many states have information on their websites specifying that data shared with the Medicaid agency will be protected. For example, the California Department of Health Care Services notes that, “When someone applies for state-funded benefits, their information is only used to determine if they qualify. State laws protect the privacy of their information.” Similarly, the Illinois Healthcare and Family Services indicates that, “Information you put on a Medicaid application will NOT be shared with U.S. Immigration and Customs Enforcement for any purpose.”

Breaches or sharing of Medicaid enrollees’ information for purposes other than the provision of health coverage and care pose risks for individuals and may jeopardize confidence in the security of data held by agencies. For example, data breaches may lead to identify theft and subsequent financial losses for individuals. Sharing of data with other entities for purposes other than administering the program without authorization may violate the privacy of individuals’ information and pose other risks. Specifically, the sharing of data with immigration enforcement officials may make individuals easier to identify for enforcement activity. Data breaches and/or privacy violations may also make individuals more reluctant to submit information to Medicaid agencies, particularly those who have immigration-related fears, which could contribute to individuals or their children going without coverage even if they are eligible.

Note: KFF’s analysis was updated on July 1, 2025 to include Wisconsin in the allocation of spending reductions due to the work requirement provision and to include Delaware in the allocation of spending reductions due to changes in state-directed payments (see KFF’s analysis of the House-passed bill for more information).

The House passed budget reconciliation package, the One Big Beautiful Bill Act, is estimated to reduce federal Medicaid spending by $793 billion, decrease Medicaid enrollment by 10.3 million people, and increase the number of uninsured people by 7.8 million. While the debate has not centered on repeal and replace of the Affordable Care Act (ACA) like the debate in 2017, several provisions in the House-passed reconciliation bill specifically target states that have adopted the ACA Medicaid expansion in various ways. Additionally, the bill would make substantial changes to how the ACA marketplaces function, and allowing enhanced ACA premium tax credits to expire would result in 4.2 million more people uninsured, according to the Congressional Budget Office (CBO). Prior KFF analysis allocated CBO’s federal Medicaid spending reductions and enrollment losses across the states, and this policy watch builds on that analysis to examine the potential impacts in expansion states compared with non-expansion states.

Provisions that would only apply to states that have adopted the ACA expansion account for roughly half ($427 billion) of the total amount of federal spending reductions in the House-passed reconciliation bill (Figure 1). These provisions include mandating that adults who are eligible for Medicaid through the ACA expansion meet work and reporting requirements ($344 billion), increasing the frequency of eligibility redeterminations for the ACA expansion group ($64 billion), imposing a federal match rate penalty for states that have expanded coverage for immigrants using state-only funds ($11 billion), and requiring additional cost-sharing for some expansion enrollees ($8 billion).

Expansion states would experience larger federal spending reductions and enrollment losses under the House-passed reconciliation bill (Figure 2). Prior KFF analysis found that federal cuts to states in the House-passed reconciliation bill would represent 12% of federal spending on Medicaid over a 10-year period and 12% of projected enrollment by FY 2034, though the shares varied by state. Expansion states would be disproportionately impacted, with federal spending cuts across expansion states representing 13% of federal Medicaid spending over the period compared with 7% across non-expansion states. Estimated enrollment losses in expansion states represent 14% of projected FY 2034 enrollment compared with 5% in non-expansion states.

Although the CBO has not yet estimated the effects of the Senate Finance Committee’s Medicaid language, there are changes to the House bill that would amplify the effects on states that have adopted the ACA expansion. The House bill prohibited states from increasing the rate of existing provider taxes, a key source of state revenues to finance Medicaid. The Finance Committee language expanded on that provision, proposing to reduce existing provider taxes, but only in states that have adopted the ACA expansion. This change could potentially reduce federal Medicaid spending in 22 states by tens of billions or hundreds of billions of dollars. Effects on hospitals would be in addition to reductions in supplemental hospital payments made by managed care organizations. The Finance Committee language would reduce those payments across a broader set of states, but the new limit would be lower in expansion states than in non-expansion states (100% and 110% of Medicare respectively). The Finance Committee language also includes a new provision to limit federal matching payments for Emergency Medicaid for individuals who would otherwise be eligible for expansion coverage except for their immigration status as well as makes changes to the federal work requirement for ACA expansion enrollees. These changes apply to expansion states only and will likely increase the total cuts that apply to ACA expansion states alone, which reached $427 billion in the House-passed bill. It is possible that new estimates of federal Medicaid cuts to ACA expansion states alone would be in the range of prior KFF estimates of federal spending reductions from eliminating the enhanced federal match rate for ACA Medicaid expansion ($626 billion).

In this research article released online by The Journal of Health Policy, Politics and Law, KFF’s Elizabeth Hamel, Alex Montero and Mollyann Brodie reflect on 30 years of public opinion data to offer perspectives on how the public accesses, evaluates, and uses health information, and what recent trends may suggest about the future of the health information (and misinformation) environment. The article examines public knowledge gaps on health and the role of partisanship in national health debates, how sources of health information have changed over time, declines in trust of information from government health agencies, and the current era of health information, including widespread uncertainty among the public and increasing use of social media and emergent technologies.

On June 18, 2025, the U.S. Supreme Court ruled (6-3) in United States v. Skrmetti, upholding the lower court’s ruling that a Tennessee law (SB1) banning gender affirming care for minors does not violate the U.S Constitution’s 14^th amendment equal protection clause. The Tennessee law, along with other states’ laws restricting gender affirming care, may stand. Access to gender affirming care in states without bans is not impacted by this decision.

As explained in the KFF brief, What to Know Ahead of the Supreme Court Case on Youth Access to Gender Affirming Care, the Supreme Court granted review for Skrmetti to resolve a split among circuits, and the ongoing questions about the constitutionality of these bans (see that brief for more background on the case). The question the Court considered was whether Tennessee’s ban on gender affirming care for minors violates the Equal Protection Clause of the Fourteenth Amendment. Embedded in its assessment, the Court considered whether the law results in sex-based classification and therefore should be reviewed with “heightened scrutiny” – that is, to show that the law is substantially related to achieving an important government objective – as opposed to the looser standard of “rational basis,” which only requires the state to show the law has a rational relation to the state’s legitimate objective.

What did the Court decide?

The Court found that because the Tennessee law classifies people based on age and medical diagnosis, it therefore does not discriminate on the basis of sex or transgender status and as such does not trigger heightened scrutiny and does not violate Constitutional Equal Protections guarantees. “SB1 satisfies rational basis review. Under that standard, the Court will uphold a statutory classification so long as there is “any reasonably conceivable state of facts that could provide a rational basis for the classification.”

Justice Sotomayor dissented, joined by Justice Jackson stating that because SB 1 does classify individuals based on sex, the Court should use heightened scrutiny, and SB 1 would fail under heightened scrutiny. Justice Kagan joined most parts of Justice Sotomayor’s decision except she filed a separate dissent to clarify she has no conclusion about whether SB 1 would satisfy heightened scrutiny.

What is the impact?

The result of the Court’s ruling means that most of the bans on gender-affirming care enacted by other states may stand as well. As of June 2025, 27 states that have enacted gender affirming care bans for minors. Bans in 25 states remain in place as a result of the ruling. Bans in Montana and Arkansas are currently permanently blocked by court order. The challenge in Montana relates to the state constitution and not federal law, and is therefore not directly impacted by the decision and the law remains blocked. A federal court blocked the Arkansas law, finding it unconstitutional based on both the Equal Protection and Due Process clauses. The Due Process claim was brought by parents stating the law took away their ability to make decisions regarding their child’s healthcare. This injunction remains in place given its basis on Due Process claims. The bans in Arizona and New Hampshire restrict only surgical care, which was not at issue before the Supreme Court, and remain in effect. Ultimately, this case leaves the patchwork of access to gender affirming care for young people in the United States in place. If a minor lived in a state without access before the decision, that access remains barred. If a minor had access to gender affirming care prior to the decision, that access remains.

There was some question as to whether the Court would apply the reasoning in Bostock, an earlier case which found that in the employment setting, sex discrimination protections apply to gender identity and sexual orientation in hiring and firing. But the Court did not do so, stating, “The Court declines to address whether Bostock’s reasoning reaches beyond the Title VII [employment] context—unlike the employment discrimination at issue in Bostock, changing a minor’s sex or transgender status does not alter the application of SB1.”

Notably, the Supreme Court heard this case narrowly on the basis of Equal Protection claims and many cases challenging state laws have been argued on multiple other grounds (including this case at the district and appellate courts). As noted, a federal district court has permanently blocked a similar ban on gender affirming care for minors in Arkansas, finding the ban violates the due process rights of parents of transgender minors. It is likely that additional cases will be filed against other state bans on due process grounds, and ultimately the Supreme Court could review a case in a future term raising 14^th Amendment Due Process, Section 1557 (the Affordable Care Act’s major non-discrimination protections), or other claims. Additionally, as noted, the Montana Supreme Court has blocked its state ban on gender affirming care for minors based on provisions in the state constitution. Litigation challenging gender affirming care based on provisions in state constitutions will also continue in state courts, , and will likely result in varying interpretations of state constitutional protections for transgender minors.

As a result of the decision, minors across the US will continue to see their access to gender affirming care determined at least in part based on where they live. However, access to these services is being debated in venues beyond the judiciary, including in Congress and by the Trump Administration. The Trump Administration has taken a range of actions aimed at limiting access to gender affirming care, especially for minors and Congress too has taken up the issue. The reconciliation bill still being finalized includes a prohibition on Medicaid covering gender affirming care in Senate and House-passed versions. These efforts will likely face, and some cases already have faced, litigation. While the ruling on this case is quite limited (narrowly focused on equal protection claims and Tennessee’s ban), it could have some bearing on the outcome of future challenges.

On May 22, the House passed the One Big Beautiful Bill Act, which the Congressional Budget Office (CBO) estimated would reduce federal Medicaid spending by $793 billion over 10 years. Over 10% of those savings came from a provision that would place a moratorium on provider taxes, keeping current taxes in place but prohibiting states from establishing any new provider taxes or from increasing the rates of existing taxes. On June 16, the Senate Finance Committee released reconciliation language expanding on that provision by also reducing existing provider taxes in states that have adopted the Affordable Care Act (ACA) Medicaid expansion. Specifically, the Finance Committee language would reduce the safe harbor limit (currently 6.0% of revenues) for states that have adopted the ACA expansion by 0.5% annually until they are within a lower safe harbor limit of 3.5%. The moratorium applies to all provider taxes, while the reduction in existing taxes would exempt nursing facilities and intermediate care facilities.

If Congress passes the reconciliation bill with the Finance Committee provision, 22 states could be required to reduce their provider taxes on either hospitals or managed care organizations, cutting a key source of state Medicaid funding in those states (Figure 1). Affected states include Arizona, California, Colorado, Connecticut, Illinois, Indiana, Iowa, Louisiana, Michigan, Minnesota, Missouri, Nevada, New Hampshire, New Jersey, New York, Oklahoma, Oregon, Pennsylvania, Rhode Island, Utah, Vermont, and Virginia.

The new restriction on states’ funding sources would apply only to states that have adopted the ACA expansion, adding another financial penalty on expansion states—in the House bill, over half of the federal spending cuts stem from provisions that only apply to expansion states. This policy watch explains how the Finance Committee provision would reduce Medicaid spending, and the implications for expansion states.

All states except for Alaska use provider taxes to help finance the state share of Medicaid spending, and those provider taxes are set in accordance with federal laws. Among other requirements, provider taxes may not hold taxpayers (providers) “harmless,” meaning that states are prohibited from directly or indirectly guaranteeing that providers will receive the taxes they pay back in the form of higher Medicaid payments, unless the provider tax comprises 6% or less of net patient revenues. The 6% limit is referred to as a “safe harbor” limit, and many states set their provider taxes below that limit so they may use provider tax revenues as a source of increased funding for hospitals and other safety net providers.

CBO’s older estimates suggest that reducing the safe harbor limit to 3.5% in expansion states could generate federal savings that are tens of billions or even hundreds of billions of dollars. Specifically, CBO estimated that reducing the safe harbor limit to 5% would reduce federal Medicaid spending by $48 billion over ten years while reducing the threshold to 2.5% would reduce federal spending by $241 billion over ten years. Those estimates apply to all states and would be somewhat lower if restricted to states that have adopted the ACA expansion.

The new limits on provider taxes in states that have adopted the ACA expansion could lead to lower hospital payment rates or reductions in Medicaid eligibility and coverage. States often use hospital provider taxes to finance higher payment rates for hospitals that serve disproportionate numbers of Medicaid or uninsured patients; some states fund the state share of the ACA Medicaid expansion or other increases in Medicaid eligibility and coverage. The House-passed version of the One Big Beautiful Bill Act is estimated to increase the number of uninsured people by 10.9 million (including 400,000 more uninsured from the provider tax provisions). CBO assumes that with limited access to provider tax financing, states would make programmatic decisions that could affect coverage. Imposing more stringent limits to provider taxes in expansion states could result in additional federal spending reductions but also could amplify negative implications for provider reimbursement rates and for coverage loss.

On May 22, the House passed a budget reconciliation bill that includes significant changes to the Medicaid program designed to reduce federal spending and enrollment, and on June 16, the Senate Finance Committee released language that could result in more significant reductions in Medicaid spending and enrollment. The Congressional Budget Office (CBO) estimated that the House bill would reduce federal Medicaid spending by $793 billion and reduce the number of people covered by Medicaid in 2034 by 10.3 million. The two largest sources of spending cuts in CBO’s estimates are establishing work requirements for adults eligible for Medicaid through the Affordable Care Act (ACA) Medicaid expansion (estimated to save $344 billion) and repealing the Biden Administration’s rules simplifying Medicaid enrollment and renewal processes (estimated to save $167 billion). Many of the reductions in coverage will be among Medicaid enrollees ages 50 and older.

The reconciliation bill could also affect access to and quality of care among older Medicaid enrollees because it includes provisions that would limit the ability of states to raise revenues to increase provider payments, limit some supplemental payments for hospitals, and pause implementation of a Biden-era rule on nursing facility staffing (although key elements of that rule were also overturned in court). Beyond the loss of Medicaid coverage, the reduction in federal Medicaid spending could spur states to make additional spending reductions by reducing covered benefits or cutting workforce payment rates that can affect care for adults ages 50 and older. This issue brief examines Medicaid coverage for the 22 million Medicaid enrollees who are ages 50 and older and implications of the provisions in the House reconciliation bill for these enrollees.

1. The 22 million adults ages 50 and older comprise 23% of Medicaid enrollees and 42% of Medicaid spending.

Adults ages 50 and older comprise 23% of Medicaid enrollment and 42% of federal and state Medicaid spending (Figure 1). The higher spending relative to enrollment is consistent with the greater health and functional needs of people as they age. Nearly half of Medicaid enrollees ages 50 and older rely on Medicaid alone for their coverage, while just over half (known as dual-eligible individuals) have Medicare as their primary source of health coverage because they are either age-eligible for Medicare (65+) or qualify due to having a long-term disability (data not shown). For dual-eligible individuals, Medicaid wraps around Medicare, paying Medicare premiums and, in most cases, cost sharing, and often pays for supplemental benefits that are not covered by Medicare, most notably, long-term care.

Even with Medicaid as the secondary payer, Medicaid spending is high for dual-eligible individuals. Dual-eligible individuals ages 50 and older account for 12% of all Medicaid enrollees but 25% of spending. Enrollees ages 50 and older with only Medicaid coverage account for 10% of Medicaid enrollment and 17% of Medicaid spending.

Relatively higher Medicaid spending among dual-eligible individuals reflects their higher rates of long-term care use. Among Medicaid enrollees who use long-term care, 63% are also enrolled in Medicare, compared to only 8% among Medicaid enrollees who don’t use long-term care. On average, Medicaid per person spending for enrollees using long term care was 8-times greater than average Medicaid spending for enrollees who did not use any long term care.

2. Over 90% of older adults with Medicaid enroll through pathways that would be affected by reconciliation provisions making it harder to enroll in and maintain Medicaid.

Among Medicaid enrollees ages 50 and older, 92% are eligible for Medicaid either through the ACA expansion pathway (27%) or through pathways that are specifically for older adults and people with disabilities (65%), both of which are disproportionately affected by the House and Senate versions of the reconciliation bill (Figure 2). In the House-passed reconciliation bill, about half of the federal spending reductions, accounting for $427 billion over 10 years, stem from provisions that only apply to states that have adopted the ACA Medicaid expansion. The biggest reductions in enrollment for expansion enrollees stem from work requirements and a new requirement for states to redetermine eligibility for expansion enrollees at least twice per year. Those changes are likely to reduce Medicaid enrollment among adults ages 50-64.

The second largest source of spending cuts in the reconciliation bill ($167 billion) stem from delaying implementation of two rules that streamline Medicaid enrollment and renewal processes until 2035. The delayed rules were expected to disproportionately increase enrollment among Medicaid enrollees eligible because they were ages 65 and older or because of a disability, who account for 65% of all older Medicaid enrollees. The first rule helps eligible Medicare beneficiaries more easily access Medicaid coverage of Medicare premiums and cost sharing while the second rule streamlines application and enrollment processes in Medicaid, including requiring states to renew eligibility only every 12 months for older adults and people with disabilities. CBO estimates that eliminating those rules would reduce the number of Medicaid enrollees by 2.3 million in 2034, 1.3 million of whom also have Medicare (dual-eligible individuals).

3. The share of adults ages 50 and older who have Medicaid coverage nationally is 14% and varies across states.

Nationally, 14% of adults ages 50 and older have Medicaid, with more than 20% of people 50 and older having Medicaid in four states and the District of Columbia (Louisiana, New Mexico, California and New York, Figure 3). Medicaid enrollees include those for whom Medicaid is their only source of health insurance and those who have Medicaid in addition to another source of coverage, including Medicare. The percentage of adults ages 50 and older covered by Medicaid tends to be higher in the 41 states that expanded Medicaid under the ACA (15%), than in states that did not expand Medicaid under the ACA (12%). Additionally, rates of Medicaid coverage among those ages 50 and older are higher in states with lower average incomes and lower rates of health insurance offered through employers.

4. More than 8 in 10 older adults on Medicaid are working or face barriers to work.

The CBO estimates that Medicaid work requirements in the House reconciliation bill, which would apply to adults ages 19-64, would reduce the number of people with Medicaid by 5.2 million. Medicaid enrollees ages 50 and older typically have lower rates of employment and increased barriers to work compared to all Medicaid enrollees ages 19-64. Among adults ages 50 to 64 with Medicaid who do not receive benefits from the Social Security disability programs, Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI), and who are not also covered by Medicare, 37% reported working full-time and 15% were working part-time. Others reported not working due to caregiving responsibilities (9%), illness or disability (20%), or school attendance (1%, Figure 4). The remaining 17% of Medicaid adults ages 50-64 reported that they are retired, unable to find work, or are not working for another reason. A 2022 CBO report found that Medicaid work requirements were unlikely to increase employment rates but would be likely to result in loss of Medicaid.

Even though both reconciliation bills provide exemptions for people based on caregiving responsibilities and illness or disability, those people still must comply with reporting requirements, increasing the risk of losing Medicaid. The provisions in the bills apply to individuals in the ACA Medicaid expansion group, so it would not include individuals who have Medicare or SSI; however, many who are enrolled in the expansion group may have a disability, despite not receiving SSI or SSDI benefits. In Arkansas, which implemented work requirements from June 2018-March 2019, about 70% of the population that had to actively report work hours lost coverage primarily due to failure to regularly report work status or document eligibility for an exemption.

5. Provisions in the House and Senate reconciliation bills could result in loss of coverage and SNAP benefits for Medicaid enrollees ages 50 and older who already report higher rates of household food insecurity compared to those without Medicaid.

The House and Senate reconciliation bills would create work requirements for the Supplemental Nutrition Assistance Program (SNAP), which could exacerbate financial challenges for older Medicaid enrollees. Medicaid enrollees ages 50 and older are over two and a half times more likely to experience household food insecurity than those not enrolled in Medicaid. Among Medicaid enrolled adults ages 50 and older, 28% live in households with food insecurity compared to 10% of those not enrolled in Medicaid (Figure 5). Among Medicaid enrollees 50 or older, nearly half (45%) were enrolled in SNAP for at least one month compared to 3% of their counterparts who were not enrolled in Medicaid. This pattern primarily reflects the significant overlap in eligibility requirements for Medicaid and SNAP, though this may vary by state and coverage population. Beyond the direct reductions proposed to SNAP, loss of Medicaid coverage may increase barriers to enrolling in SNAP as many states use Medicaid enrollment to determine eligibility for other public benefit programs, including SNAP.

Note: Originally published on May 13, 2025, this analysis has been updated with the latest estimates from the Congressional Budget Office for the House-passed version of the One Big Beautiful Bill Act.

House Republicans have passed a reconciliation package (the “One Big Beautiful Bill Act”) that would make significant changes to Medicaid and the Affordable Care Act (ACA). For example, provisions in the legislative text include work and reporting requirements for certain Medicaid enrollees and codify changes from a recent Trump Administration proposed rule on the ACA Marketplaces, among other policy changes.

These policy changes also come at a time when large health insurance coverage losses are expected if enhanced premium tax credits for ACA marketplace coverage expire at the end of 2025. The expiration of the enhanced tax credits will increase out-of-pocket premiums substantially and likely lead to millions of people dropping their coverage.

The Congressional Budget Office (CBO) estimates that, taken together, these changes will result in 16 million more uninsured people in the year 2034 than would otherwise be the case, including:

• 7.8 million more uninsured resulting from Medicaid changes in the One Big Beautiful Bill Act (OBBBA)
• 3.1 million more uninsured from OBBBA provisions affecting the ACA Marketplaces
• 900 thousand more uninsured from codifying the recent Trump Administration proposed rule on the ACA Marketplaces. This accounts for only half the effect of the proposed rule; the remaining 900 thousand people becoming uninsured are included in the effects of ACA provisions in the reconciliation package.
• 4.2 million more uninsured with the expiration of the enhanced premium tax credits, relative to an estimate of a permanent extension of those credits

This would represent a significant increase in the uninsured rate in most states, and it would come after years of declining uninsured rates following implementation of the ACA.

Medicaid Provisions

The Medicaid provisions in the House Reconciliation bill would increase the number of people without health insurance by at least 7.8 million in 2034, according to estimates by the Congressional Budget Office. The increased number of people without health insurance stems from multiple provisions that would reduce federal spending on Medicaid by $793 billion over 10 years and reduce Medicaid enrollment by 10.3 million. Some of the provisions that would likely cause significant numbers of people to lose health insurance are described below.

Fewer people would be enrolled in Medicaid through the ACA expansion because:

• People eligible through the expansion would have to meet new work and reporting requirements.
• States would be required to renew eligibility for expansion enrollees at least two times per year and impose new cost sharing requirements.
• Fewer states might offer the ACA expansion than might otherwise be the case because the bill would eliminate an added incentive for states to adopt it.
• Expansion states would also receive lower federal matching rates if they cover immigrants with state-only funds, regardless of immigration status.

Other provisions would affect all enrollees (not just expansion enrollees):

• New requirements added under the Biden administration for states to streamline Medicaid eligibility and enrollment would be delayed until January 1, 2035, which would increase barriers to enroll in and renew Medicaid coverage, especially for older adults and people with disabilities.
• The bill would create new requirements for verifying addresses, cross-checking eligibility and data against other sources, and would reduce retroactive coverage from three months to one month.
• The bill would eliminate the reasonable opportunity period for verification of immigrant status in all states, during which people receive coverage.

One Big Beautiful Bill Act Changes to the ACA Marketplaces

Proposed Rule Codification

The One Big Beautiful Bill Act codifies policy changes laid out in a recent Trump Administration proposed rule on program integrity. The CBO expects these policy changes to increase the number of uninsured people by 1.8 million by the year 2034. Half of the 1.8 million impact is considered in the baseline while the other half (900K) are accounted for in the impacts of the legislation.

Some of the key changes to the Marketplace from the proposed rule and the One Big Beautiful Bill Act are described below. (More information on additional provisions can be found here.)

• Shortens the Open Enrollment Period: In the past few years, the annual open enrollment period has lasted from November 1 to January 15, with some state-based exchanges having longer enrollment periods; the proposed rule and the legislation would end the open enrollment period a month earlier, on December 15.
• Restricts the types of Special Enrollment Periods (SEPs): The proposed rule eliminates the year-round enrollment opportunity for people with incomes up to 150% of poverty (the low-income SEP). SEPs allow individuals to enroll in Marketplaces outside the annual open enrollment period. The legislation would go further than the proposed rule by limiting the ability of all Marketplaces (including SBMs) to provide specific types of SEPs, such as the low-income SEP, that are based on the relationship of people’s income to the poverty line.
• Creates a new $5 monthly charge for certain auto-enrollees: Under the proposed rule, enrollees with a zero-dollar premium (after tax credits) who are automatically re-enrolled in Marketplace coverage and do not proactively verify their ongoing eligibility for a fully subsidized plan will face a $5 monthly charge until they actively confirm their eligibility. Legislation includes the same requirement, described as a reduction in advance payment of premium tax credits.
• Imposes new documentation requirement for individuals to verify income in specific situations when applying for premium tax credits: The proposed rule and legislation would require individuals to verify their projected income by providing additional documentation where the Internal Revenue Services has no tax return data for the individual for the prior year. Documentation would also be required where IRS data indicates that an applicant’s income for the prior year was below the poverty level.
• Restricting coverage for DACA recipients: The proposed rule and legislation disqualify Deferred Action for Childhood Arrivals (DACA) recipients from ACA Marketplace coverage by excluding this group from the definition of “lawfully present.” Additional provisions in the legislation also explicitly prevent DACA recipients from receiving tax credits.

Additional Marketplace Changes

Other provisions in the legislation go beyond codifying the proposed Marketplace integrity rules.

• Repayment of excess tax credits: Enrollees whose incomes are different than what they originally estimated must reconcile the amount of tax credit they received with the amount they are determined to be eligible for at the time they file their taxes the following year. This provision would eliminate repayment caps for excess tax credits received.
• Appropriating cost sharing reduction (CSR) funding: OBBBA would reinstate government funding for CSRs, effectively ending “silver-loading.” Funding is prohibited for health plans that cover abortion services except when abortion is necessary to save the life of the mother, or if the pregnancy is a result of an act of rape or incest. (For more on CSR appropriation, see this brief ).
• Pre-enrollment verification: Requires that income, immigration status, health coverage status, place of residence, family size, and any other information that the Secretary of Health and Human Services deems necessary are verified before coverage. Consumers may still enroll in a plan at full price if they can afford to do so, but they cannot receive premium tax credits or cost-sharing reductions (CSRs) until after they verify their eligibility. This provision would also effectively end auto-renewals.

Expiration of Enhanced Tax Credits

The CBO projects that 4.2 million more people will be uninsured in 2034 if enhanced ACA tax credits expire. The enhanced premium tax credits were originally passed by Congress in the American Rescue Plan Act (ARPA) and extended under the Inflation Reduction Act (IRA), but they are set to expire at the end of 2025. The enhanced tax credits both increased the amount of financial help for those already eligible under the ACA and expanded eligibility to those making more than four times poverty ($124,800 for a family of four in 2025), capping premium payments for a benchmark plan at 8.5% of their income. On average, the enhanced tax credits have reduced premium payments by $705 a year on average for enrollees receiving tax credits.

The enhanced premium tax credits have led to the ACA Marketplace more than doubling in size since 2020. States that President Trump won account for 88% of Marketplace enrollment growth since 2020. In some of these states, like Texas and Georgia, at least 10% of the population in a majority of congressional districts is now enrolled in a Marketplace plan. In Florida, at least 10% of the population in all congressional districts is enrolled in the ACA Marketplace.

The expiration of the enhanced tax credits is expected to cause ACA enrollees’ out-of-pocket premium payments to increase by over 75% on average, with people in some states seeing their payments more than double on average. Lower-income and older enrollees, as well those who live in states that have not expanded Medicaid, are expected to see the most significant premium payment increases.

With the Affordable Care Act’s (ACA) enhanced premium tax credits set to expire at the end of 2025, a large majority (77%) of the public favor Congress extending the credits while about one in five (22%) say they should let them expire, the latest KFF Health Tracking Poll finds.

Majorities of Democrats (91%), independents (80%), and Republicans (63%) say the enhanced tax credits should be extended by Congress, as do more than half (56%) of Republicans and Republican-leaning independents who identify as supporters of President Trump’s Make America Great Again movement (MAGA).

Since 2021, the enhanced premium tax credits have helped lower what consumers pay for ACA Marketplace coverage and fueled record enrollment in the program. Without the tax credits, Marketplace enrollees could see what they pay out-of-pocket for premiums rise by more than 75%, and the Congressional Budget Office estimates that more than 4 million people would end up uninsured.

The poll also finds that most (72%) of the public have heard little or nothing at all about the enhanced tax credits, and people’s views on whether to extend them can shift when presented with different facts and arguments about their impact.

When those who initially support extending the credits hear that it would require significant federal spending and increase the nation’s budget deficit, overall support drops from 77% to 58%.

On the other side, when those who initially oppose extending the credits hear that letting them expire would make health insurance unaffordable and increase the number of uninsured, overall support rises from 77% to 84%.

Designed and analyzed by public opinion researchers at KFF, this survey was conducted June 4-8, 2025, online and by telephone among a nationally representative sample of 1,321 U.S. adults in English and in Spanish. The margin of sampling error is plus or minus 3 percentage points for the full sample. For results based on other subgroups, the margin of sampling error may be higher.